Provider Demographics
NPI:1033143912
Name:MATHEW, LOURDES M (MD)
Entity Type:Individual
Prefix:MRS
First Name:LOURDES
Middle Name:M
Last Name:MATHEW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 NORTH THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:31748
Mailing Address - Country:US
Mailing Address - Phone:352-728-2532
Mailing Address - Fax:352-728-3004
Practice Address - Street 1:732 NORTH THIRD STREET
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:31748
Practice Address - Country:US
Practice Address - Phone:352-728-2532
Practice Address - Fax:352-728-3004
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME24875207R00000X, 207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35146OtherBCBS
FL056387100Medicaid
FL056387101Medicaid
FL35146OtherBCBS
D54333Medicare UPIN